Understanding the Report Card
Objective Categories and Measures
The Report Card is based on 136 objective measures that reflect the most recent data available from high-quality sources such as the Centers for Disease Control and Prevention, the National Highway Traffic Safety Administration, the Centers for Medicare & Medicaid Services, and the American Medical Association. Additional data were gathered from two surveys of state health officials, specifically conducted to obtain information for which no reliable, comparable state-by-state sources were available. The goal of the Report Card is to show how individual states, and our nation as a whole, measure up in supporting the ability of the nation’s emergency departments to care for patients.
The Report Card also reviews the emergency medical environments for Puerto Rico and Government Services, which includes health care systems for the military and veterans. These, however, present special cases, since data for these areas are not comparable to the 50 states and District of Columbia. As such, grades were not calculated. The report for Puerto Rico is based on a limited set of indicators for which comparable data were available and the Government Services report is based on in-depth interviews with representatives of each of the military branches and the Veterans Health Administration.
The five categories and indicators included in the 2009 Report Card served as a starting point for determining the indicators to be used in the 2014 Report Card. The Report Card Task Force, a panel of experts in emergency medicine and related topics, chose to maintain the five categories, as well as the vast majority of indicators, from the 2009 Report Card and recommended the addition of new indicators that could provide greater depth in each of the categories. Factors such as the availability of consistent state-level data, issues that are of current importance to the field, and the consistency of measurement over time were considered by the Task Force in selecting indicators. In total, 136 indicators were selected because they represent factors that are vital to the provision of lifesaving emergency care. Each indicator also met several key criteria: relevance, reliability, validity, reproducibility, and consistency across all of the states. A more detailed description of the Report Card data, the Report Card Task Force processes, and the grading methodology are presented in the Appendices. The specific issues involved in comparing grades and ranks between the 2009 and 2014 Report Cards are discussed in the next section.
The 2014 Report Card includes a wide range of indicators that represent both direct measures of emergency medical services and many indirect measures that have an important effect on the ability to provide quality and timely emergency care. They are classified according to five categories: Access to Emergency Care, the Quality and Patient Safety Environment, the Medical Liability Environment, Public Health and Injury Prevention, and Disaster Preparedness. For each state and the nation as a whole, the Report Card presents one grade for each of the five categories and an overall grade.
Access to Emergency Care (30% of total grade)
Subcategories: Access to Providers (25% of the category), Access to Treatment Centers (25%), Financial Barriers (25%), Hospital Capacity (25%)
Access to emergency care is both fundamental and complex. Emergency departments are a vital part of the health care system in each community and region. They deliver emergency care day in and day out, and they serve as the health care safety net for anyone, insured or not, who cannot otherwise obtain timely health care services when needed. Access to emergency care is complex because the demand for emergency services often is related to the capacity of the broader health care system to deliver services. Thus, measures of Access to Emergency Care must include elements that comprise that broader system.
This category measures the availability of emergency care resources, such as numbers of emergency physicians, emergency departments, registered nurses, and trauma centers per person, along with proximity to Level I or II trauma centers, and the median time from arrival to departure from the emergency department. Because emergency department capacity is also a function of the broader health care system, the access category includes key measures of that system’s capacity, such as the availability of primary care, mental health care, and substance abuse treatment. It also includes the numbers of available inpatient hospital beds, psychiatric beds, and designated pediatric specialty centers, because greater capacity in those areas can alleviate crowding and boarding within emergency departments. Since one of the most commonly cited concerns in emergency departments across the country is the lack of access to on-call specialists, this category also includes measures of the total supply of commonly requested specialists, including neurosurgeons, orthopedists, hand surgeons, plastic surgeons, and ear, nose, and throat specialists. As an example of the complexity of the access issue, it should be noted that while the number of specific specialists is measurable, many of these specialists have curtailed their availability for emergency services for any number of reasons, including conflicting clinical responsibilities and the cost and risk of medical liability when caring for emergency patients.
Finally, another critical issue that affects the demand for and access to emergency care is the ability of patients to pay for needed health services. Emergency departments are obligated under the unfunded government mandate of the Emergency Medical Treatment and Labor Act (EMTALA) to screen and stabilize individuals with emergency medical conditions(10). Therefore, the percentage of adults and children who are uninsured or underinsured, the number of people relying on public health insurance such as Medicaid, and the availability of physicians to treat those patients are included as important measures of the demand for care that must be absorbed by the emergency medical system. It is expected that these factors will change as components of the Affordable Care Act are implemented.
Quality and Patient Safety Environment (20% of total grade)
Subcategories: State Systems (66.7% of the category), Institutions (33.3%)
One of the critical concerns regarding the increasing pressures on our emergency medical system is the effect these pressures may have on the quality and patient safety environment. Therefore, it is important to be able to measure that environment and how improved systems and technologies can contribute to its enhancement. State governments and private institutions, led by federal agencies, have made great advances over the past five years in the development and implementation of indicators of health care quality, and this is reflected through the expansion in the indicators measured here since the 2009 Report Card. We continue to monitor direct state investments in quality and safety improvements—for example, whether a state provides funding for quality improvements to EMS or for a State EMS Medical Director.
Additional measures of state investments in the quality and patient safety arena include the percentage of counties that have Enhanced 911 services and the number of emergency medicine resident physicians in the state relative to the population. The latter number is important because research shows that investment in emergency medicine residency programs helps increase the numbers of emergency physicians since most choose to stay and practice in or nearby the state where they are trained.
Further measures of quality improvement systems include systems of care for specific conditions, such as stroke or myocardial infarction (heart attack), and uniform systems for providing pre-arrival instructions. Indicators have also been added to assess state-level efforts to implement prescription drug monitoring programs to control the abuse of prescription painkillers, as well as indicators of triage and destination policies for stroke, ST-elevation myocardial infarction (STEMI, or heart attack involving blockage of a major artery), and trauma patients.
On the institutional level, indicators are included that measure the adoption of systems that may contribute to improving the quality of care, such as computerized practitioner order entry and electronic medical records. Several direct measures of quality are included as well: the percentage of patients with acute myocardial infarction given aspirin with 24 hours of arrival in the emergency department, the percentage of these patients given percutaneous coronary intervention (PCI) within 90 minutes, and the median time to transfer to another facility for acute coronary intervention. Finally, since equity is an essential component of quality, two indicators were added that address institutions’ attention to health equity: the percentage of hospitals collecting data on the race, ethnicity, and primary language of their patients, and the percentage of hospitals who have or are working on a diversity strategy or plan.
Medical Liability Environment (20% of total grade)
Subcategories: Legal Atmosphere (25% of the category), Insurance Availability (20%), Tort Reform (55%)
According to the U.S. Department of Health and Human Services, the medical liability system in our nation is “broken”(11). There are wide variations in practices and policies across states. In some states, high liability insurance rates have forced physicians to curtail their practices, stop performing high-risk but critically necessary procedures, such as delivering babies or providing on-call specialty care to emergency patients, or move to other states with more favorable liability environments. The liability crisis has forced the closure of trauma centers in some states. Physicians may practice “defensive medicine”—providing extra medical treatments or tests solely out of concern to avoid litigation. For patients, the result is greater costs, longer waits, and more difficulty accessing care. For our nation, the result is increased health care expenditures. Studies estimate that medical liability costs add between $55 billion and $108 billion to the total cost of health care each year(12). At the lowest estimate, these costs account for 2.4% of total health care expenditures. In 2012, the average state’s medical liability insurance premium for internal medicine was $13,338, with the highest average premium reaching $31,133. For obstetrician/gynecologists and general surgery specialists, the insurance premium in the average state was $57,459 per year, but reached as high as $128,555(13). High medical liability insurance rates and fear of lawsuits, particularly in the higher risk environment of the emergency department, may lead to reductions in the numbers of specialists willing to offer on-call services to emergency departments(14).
For instance, a recent study assessing malpractice risk by physician specialty indicates that every year about 20% of neurosurgeons and nearly 15% of orthopedists and plastic surgeons face a malpractice claim(15). Another recent study has estimated that physicians can expect to spend 11% of a 40-year career with an unresolved medical malpractice claim which further contributes to the emotional burden of high-risk practice(16). High insurance costs and the risk of malpractice claims also discourage medical students from going into high risk, but critically important specialties, such as emergency medicine, surgery, neurosurgery, orthopedics, and obstetrics.
Further aggravating the situation is evidence that the lack of access to on-call specialists contributes to adverse patient outcomes because of delayed treatment or the need to transfer patients long distances to obtain the care they need (14).Two-thirds of emergency department directors in Level I and II trauma centers surveyed by ACEP in 2006 reported that more than half of the patient transfers that they received were referred there because of a lack of timely access to specialty physicians in the emergency department of origin(17). In other words, a medical liability environment in crisis may result in a greater risk of adverse outcomes for patients.
In the face of rising medical liability insurance costs and physician shortages, all but 5 states and the District of Columbia introduced some type of medical liability reform legislation in 2011 and 2012(18). However, many of the reforms have not passed, and in some cases those that were enacted have been reversed by state judicial systems. In addition, the extent and types of liability reforms vary significantly across states.To assess the status and variation of these measures, this Report Card category includes data on numerous types of liability reforms, based on a detailed review of existing legislation impacting the liability environment in each state. Examples of reform indicators include medical liability caps on non-economic damages, pretrial screening panels, periodic payments of malpractice awards, the presence or absence of a state-funded patient compensation fund, and additional liability protections for EMTALA-mandated care. There are several indicators related to expert witness rules and a measure of whether or not the state has abolished joint and several liability.
Further measures of the liability environment in this category include information on the numbers of malpractice award payments, average value of awards, and average liability insurance premium costs. The 2014 Report Card also includes state apology inadmissibility laws, as well as whether states provide for malpractice awards to be offset by collateral sources.
Public Health and Injury Prevention (15% of total grade)
Subcategories: Traffic Safety and Drunk Driving (22.2% of the category), Immunization (16.7%), Fatal Injury (16.7%), State Health and Injury Prevention Efforts (22.2%), Health Risk Factors (22.2%)
Nearly one-third (31.5%) of emergency visits are for injury-related causes. In addition, more than half of the causes of death and disability are due to preventable and behavior-related factors, such as smoking, poor diet, lack of physical activity, alcohol consumption, motor vehicle crashes, firearms, and illicit drug use (19,20). Consequently, the impact of public health and injury prevention on the need for emergency care and other health care services is considerable, and state investments in these areas are important.
The public health measures include such indicators as rates of obesity among adults and children, cigarette smoking, and binge drinking. They also include infant mortality rates as well as adult and child immunization rates, each of which is an important measure of access to primary care services that are proven to greatly reduce morbidity and mortality. To recognize the growing issues of health equity, indicators have been added that measure racial and ethnic disparities in the critical public health indicators of cardiovascular disease, human immunodeficiency virus (HIV) diagnosis, and infant mortality. The rates of traffic fatalities, including those that are alcohol-related, are represented, as are homicides and suicides and fatal injuries from falls, fires, firearms, and occupational incidents.
In recognition of the increasing rate of drug-overdose deaths, which has surpassed that of traffic-related deaths, the rate of unintentional poisoning deaths has been newly added in this Report Card. Within injury prevention, there are measures of seatbelt use, state policies on seatbelts and child safety seats, and legislation on distracted driving and graduated drivers’ licenses, as well as state investments in various forms of injury prevention programs. Wherever possible, the indicators in this section were designed to measure the outcomes of prevention efforts—such as rates of seatbelt use and traffic fatalities—in addition to the policies, such as seatbelt laws, that may influence safe behaviors.
Disaster Preparedness (15% of total grade)
Subcategories: Financial Resources (13.3% of the category), State Coordination (40%), Hospital Capacity (20%), Personnel (26.7%)
Threats of terrorism and the number of disasters of natural and human origin in the United States continue to increase, highlighting the fact that at no time in our history has the need for disaster preparedness been more urgent or pronounced. Several factors, such as population growth, greater urbanization, population migration to states at higher risk of natural disasters, and decreased health care access and capacity have magnified the potential effects of disasters on individuals and infrastructure. Emergency physicians have training and experience in managing mass casualty events and delivering lifesaving care to the sick and injured. As such, they play an integral role in local and national disaster preparedness and response. However, while there has been increased state and federal focus on disaster preparedness, there is great variability among states in terms of planning and response capacity. In addition, there is increasing concern regarding the fact that the emergency care system in many communities is already stretched to the limit, and that surge capacity, staffing, and resources are inadequate to deal with the extraordinary demands of a major disaster.
To measure support for disaster preparedness and response, this category includes numerous measures of disaster planning, capacity, and systems that are designed to ensure a quick and effective response. Examples of those measures range from levels of federal funding received by each state for disaster preparedness to training, drills, bed surge capacity, and numbers of burn beds and intensive care unit beds per capita. There are several indicators associated with medical response plans and the degree to which they incorporate emergency physician input, patients with special health care needs, and communication with emergency and hospital staff.
Indicators also measure development of communication and tracking systems, including “just-in-time” training, redundant communication, patient tracking, and syndromic surveillance. The presence or absence of medical strike teams and liability protection for health care workers during a disaster is included as is the level of participation by physicians, nurses, and behavioral health professionals in the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP).
Comparing the 2014 and 2009 Report Cards
Environment of the 2014 Report Card
The 2014 Report Card evaluates the conditions under which emergency care is delivered during a time of mounting pressure — it does not attempt to measure the quality of care provided by hospitals and emergency providers. Emergency physicians are trained to respond to urgent and emergent care needs; however, they are increasingly playing a key role in disaster response due to the rise of mass-casualty events and natural disasters. They are also increasingly tasked with coordinating transitions of care and providing care for patients with limited immediate or long term access to primary care providers. While some states have instituted policies and systems that will help to lighten the load on their overburdened emergency care system, as demonstrated in this Report Card, others are clearly falling short.
Differences between the Report Cards
The 2009 and 2014 Report Cards are similar in several important ways. First, the five categories of indicators remain the same (Access to Emergency Care, Quality and Patient Safety Environment, Medical Liability Environment, Public Health and Injury Prevention, and Disaster Preparedness) as do their relative contribution to the overall grades. Second, there is extensive overlap in the specific indicators included in both Report Cards. In total, 108 of the 116 measures included in the 2009 Report Card are retained in this Report Card (a few measures were retired because data were no longer available or they were no longer pertinent to the overall Report Card). Third, the methods used to score and grade the states in this Report Card are the same as those used for the 2009 Report Card.
The benefit of these similarities is that they allow direct comparisons between Report Cards. It is important to note, however, that the states are graded in this Report Card (and in the 2009 Report Card) in relation to other states, so the grades are not an absolute measure of a state’s support for its emergency care system. Therefore, a change in a given state’s grade reflects changes in that state’s emergency care environment, as well as changes in other states’ scores – both of which will affect the state’s rank and grade. (More detail about the scoring and grading of states is provided in the Methodology section.) For this reason, it may be most appropriate to compare values for specific measures and state rankings over time. In this regard, the 2014 Report Card helps to identify both areas of improvement relative to 2009 and areas that require immediate attention.
Although similar in content and methodology, this Report Card includes a number of measures that were not presented in the 2009 version, increasing the total number of measures by 20. Most of these additional measures fall under the categories of Public Health and Injury Prevention, Quality and Patient Safety Environment, and Disaster Preparedness; several measures were also added to the remaining two categories. Individual measures are reported on the state data pages.
Highlights of the 2009 Report Card
In January of 2009, ACEP published its second National Report Card on the State of Emergency Medicine, which incorporated substantial revisions to both the content and methodology relative to ACEP’s first Report Card, published in 2006. The 2009 Report Card included 116 measures across five categories: Access to Emergency Care, Quality and Patient Safety Environment, Medical Liability Environment, Public Health and Injury Prevention, and Disaster Preparedness. Measures and grades were reported for each state in the nation, as well as for the District of Columbia.
Overall, the nation received a C- grade for its support of emergency care in 2009. The nation fared best but was still under par in the area of Public Health and Injury Prevention, receiving a C grade for this category, and it was worst in the area of Access to Emergency Care, receiving only a D- grade for this category. While none of the states earned straight A’s, several states were ranked among the best (the top 5) in more than one category. Likewise, none of the states failed across the board, but several states ranked among the worst (the bottom 5) in more than one category. Individual overall state grades ranged from a B in Massachusetts to a D- in Arkansas.
The 2009 Report Card presented findings that were considered “sobering” and pointed to a national emergency health care system that was in serious condition. Concerns related to emergency department boarding and crowding were paramount in 2009, particularly because numerous trends, such as an increasing number of patients using emergency departments and a subsequent decline in the number of emergency departments open to serve this population, underscored the need for reform.
Issues, such as the cost and availability of medical liability insurance, the shortage of on-call specialists, inconsistent use of systems and standards of care within states, and the less than ideal coordination of emergency services only compounded the seriousness of the situation. To combat these multiple pressures, the 2009 Report Card made the following recommendations:
- Create stronger emergency departments through national health care reform.
- Alleviate boarding in emergency departments and hospital crowding.
- Pass the Access to Emergency Medical Services Act.
- Enact federal and state medical liability reform.
- Infuse a greater level of federal funding and support into disaster preparedness and response.
- Increase support for the nation’s health care safety net.
- Develop greater coordination of emergency services.
- Increase the use of systems, standards, and information technologies to track and enhance the quality and patient safety environment.